Forsyth_Well Abandonment_20240903

WELL ABANDONMENT RECORD For lmcrt,altiseONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLSONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: 416708
1,isl all upphcuhle Nell constnicuon penwls(i.e. 111C.Couniv,Siale, Variance.etc.)1fknoi+'tr 1 2 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout O Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) e Concrete Grout ! ❑Drill�uttings
❑Irri ation ❑ Specialty Grout _ r ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry J t P '� LOZB Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each matelt lail sefected above,pfawide ainotint of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 8 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer
❑Geothermal(1-leating/Cooling Return) ❑Other(explain under 7g) Poured concrete directly into well tiles / casing
and filled to within 3 feet of surface where
4.Date well(s)abandoned: 8/15/24 a concrete plug was installed on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
5501 Yadkinville Road Z _ 8/16/24
Physical Address,City,and Zip Si tu gnare ofCcrtified Well ecintractor or Wcll Owner Date
Pfafftown, NC 27040 �0rsO) 5897-14-8404
By signing this form, /hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 0100 or 2C.0200 Well Construction Standards
>b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy,of this record has been provided to the well owner.
(if well field.one lat/long is sufficient) 9.Site diagram or additional well details:
36.144762 N 80.382439 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBI\UTTAL INSTRUCTIONS
Atlach Nell conc/ruclion record(.v ifavatlahle. 1•Lr multiple iiUecuon ornotr-wanersupply u•ellr
ONLY with the same construction ahandonnienl,you can.cuhmil one f um.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: `SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 51 (ft.) 1617 Mail Serx'ice Center,Raleigh,NC 27699-1617
lob. For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter:
20 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 41 (ft-) Division of Water Resources,Underground Injection Control Program,
1636;Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft) l0c.For Water Suoaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known). Unknown (ft) abandoned.
6g.Screen length(if known): Unknown
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016